Makindo Medical Notes

Related Subjects: |CEA |ALP |LDH

With effective treatment, the overall five-year survival rate is 97%. Orchidectomy is both diagnostic and therapeutic. For patients desiring future fertility, sperm banking should be discussed early in the course of treatment.

About

• Testicular cancers - 95% are tumour of primordial germ cells
• Commonest solid tumour in men age 20-40
• If Age > 50 then consider lymphoma
• Seminomas have the best prognosis with an over 90% cure rate
• Choriocarcinomas have the worst prognosis

Aetiology

• Germ cell tumours are differentiated into Seminomas 50% and Non-seminomatous (NS)
• Treatment and prognosis and tumour markers differ
• Right testis drains to just below right renal vessels (interaortocaval)
• Left testis drains to para-aortic nodes just below left renal vessels

Risks

• Undescended tests/Cryptorchidism abdominal worse than inguinal - risk reduced by early orchiopexy or removal
• Personal or family history of testicular cancer
• Testicular feminisation syndrome
• Klinefelter's syndrome (mediastinal Germ cell tumour s)
• Caucasians are at higher risk

Quick Comparison

• Seminomas spread late, Non-Seminomas spread early
• Seminomas very sensitive to radiotherapy
• Seminomas cured in 90% - Non-Seminomas less depending on type/stage
• Seminomas occur in the older group than non-seminomatous

Clinical

• Painless hard or firm testicular mass or scrotal pain or dull ache suggesting orchitis or epididymitis (always get testicular USS in age 20-40)
• Firmness of the testis, Painless, solid testicular, Scrotal heaviness or Scrotal swelling, Gynaecomastia with high Beta-HCG.
• Symptoms from metastatic disease or retroperitoneal lymphadenopathy or Chest disease such as Gynaecomastia, Headaches Low back pain, Neck mass, cough, dyspnoea, haemoptysis

Investigations

• FBC, U&E, LFT, ALP, Calcium
• Urine: pregnancy test may be positive
• LDH: elevated in both seminoma/non seminoma, found in many tissues and correlates with tumour bulk. It's an important prognostic marker and is part of the staging and risk assessment in testicular cancer management.
• Serum Beta HCG and Alfa fetoprotein- elevated mainly in Non-Seminomas falls with treatment and rise with recurrence and checked post orchidectomy
• CXR: cannon ball metastases here
• An FNA or percutaneous biopsy should not be carried out under any circumstances
• Chest radiography and abdominal/pelvic computed tomography (CT) should be performed to assess for metastasis.
• Brain magnetic resonance imaging or a bone scan if signs or symptoms

• USS of testes and consider Radical inguinal orchidectomy (RIO)
• Look for symptoms of spread - breathless - CXR, back pain - retroperitoneal metastases

Types of Tumours: 95 % are Germ cell tumour s

• Germ cell tumour are derived from germ cell neoplasia in situ and are divided into seminomas and Non seminomatous germ cell tumours
  • Seminoma germ cell tumours
  • Nonseminomatous germ cell tumours
    • Embryonal carcinoma
    • Yolk sac tumour (post pubertal)
    • Trophoblastic tumours (e.g., choriocarcinoma, placental site trophoblastic tumour )
    • Teratoma (post pubertal) with or without malignant transformation
  • Mixed and unclassified germ cell tumours
• Others < 5 % Not derived from germ cell neoplasia in situ
  • Spermatocytic tumour
  • Teratoma (prepubertal)
  • Yolk sac tumour (prepubertal)
  • Sex cord–stromal tumours (< 5% of all testicular cancers)
  • Leydig cell tumour
  • Sertoli cell tumour
  • Granulosa cell tumour
  • Mixed and unclassified sex cord–stromal tumours
  • Mixed germ cell and stromal tumour (proportion of all testicular cancers not well defined)
  • Gonadoblastoma
  • Miscellaneous tumours (proportion of all testicular cancers not well defined)
  • Ovarian epithelial-type tumours
  • Haemangioma
  • Haematolymphoid tumours
  • Tumours of the collecting duct and rete testis(adenocarcinoma

Staging

• Stage I: Tumour confined to the testis, epididymis, spermatic cord
• Stage II: Distant spread to retroperitoneal nodes below diaphragm
• Stage III: Metastases outside retroperitoneal nodes or above the diaphragm

Treatment

• Patients with suspected urological cancer should be referred from GPs to local urology units, urgently, according to the 2 week wait criteria. Consider a suspected cancer pathway referral (< 2 weeks) for testicular cancer in men if they have a non‑painful enlargement or change in shape or texture of the testis. Consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms.
• Surgical options for Suspicious mass seen on USS is Radical inguinal orchiectomy is usually removal of the testes Answermatic cord to the internal inguinal ring, is the primary treatment for any malignant tumour found on surgical exploration of a testicular mass. Testis-sparing surgery is generally not recommended but may be performed for a small tumour in one testis or for small bilateral tumour s. Orchiectomy may be delayed if life-threatening metastases require more urgent attention.
• Seminoma Germ cell tumour
  • Very sensitive to radiotherapy and Best prognosis. Over 90% cure. they are completely undifferentiated cells tend to form a seminoma. Pathology shows sheets of uniform cells. Grey homogenous material. It Stains for placental Alkaline phosphatase. If it contains syncytiotrophoblasts then serum Beta-HCG raised. Tend to remain localised until late and then spread to Lymph nodes. Very sensitive to radiotherapy and Best prognosis. Over 90% cure.
  • Seminoma - Orchidectomy + radiotherapy to retroperitoneal nodes as this is where the initial spread is usually local and late. Orchidectomy should be done carefully via removal of the testis, epididymis and spermatic cord via an inguinal incision. A biopsy is not done as this can lead to tumour spillage which will mean the removal of scrotal skin and local spread etc. Suspicion usually leads to radical orchidectomy and biopsy foregone.
• Non Seminomatous Germ cell tumour (NSGCT)
  • Metastasis early usually haematogenous and have worse prognosis than seminomas. Spread to lung and liver. Not very sensitive to radiotherapy. AFP and HCG detected.
  • Yolk sac tumour - marked rise in AFP and HCG. Children aged 3. Good prognosis.
  • Embryonal carcinoma : age 20-30. More aggressive than seminomas. AFP and HCG detected.
  • Choriocarcinoma: Highly malignant. Cytotrophoblastic and syncytiotrophoblastic cells. Usually testicular enlargement is small. Haemorrhagic and necrosis. HCG found.
• Teratoma
  • Poor prognosis factors include: Mediastinal primary or Non-pulmonary visceral metastases (NPVM) or AFP>10,000 ng/L or HCG>50,000 iu/L or LDH >10 x upper limit of normal
  • Treatment: primary treatment will be 4 cycles BEP/EP (5 day regimen) plus interval Bleomycin, followed by reassessment after 4 cycles. Depending on outcome, proceed to 2 further cycles, elective surgery or no further action
• Poorer prognosis
  • Non seminomatous germ cell tumour
  • Lactate dehydrogenase >10 times the upper limit of normal
  • Human chorionic gonadotropin >50,000 IU/mL
  • Alpha-fetoprotein >10,000 ng/mL
  • Non pulmonary visceral metastases (e.g., bone, liver, brain)
  • Any primary mediastinal non seminomatous germ cell tumour

References

• NHS guidelines
• Testicular Cancer:Diagnosis and Treatment 2018

Summary

Less common tumours